Coulter Donation Form
Coulter Art Gallery Donation Form
100% of donations benefit Phoenix Children's Center for Cancer and Blood Disorders
PLEASE PRINT & VERIFY SPELLING!
DONOR INFORMATION
ID #_________________
For Internal Use Only
Title (Check One): Mr.
Mrs. Ms.
Dr. Other ____________________
First Name: _________________ Middle Initial: _____ Last Name: _____________________ Suffix: ________
Spouse Name: ________________________________
Address: _________________________________________________________________
HOME BUSINESS
City: _____________________________ State: ________ Zip Code: ______________
Company Name (only if business donation): _______________________________________________________________
HOME WORK
Phone 1: (_____) ___________________ CELL OTHER
Phone 2: (_____) ___________________
E-Mail: _______________________________________ (To email donation receipt)
GIFT INFORMATION
Step 1: ARTWORK TYPE -SELECT ONE:
Matted Artwork $50 SMALL $100 (8 x 8, 12 X 12 canvases) MED $250 (20 x 20, 18 x 24 canvases) LARGE $500
Step 3: SPECIAL REQUESTS:
TRIBUTE GIFTS:
IN MEMORY OF...
IN HONOR OF...
Name: ______________________________________________
Send Notification Letter to: Name: ______________________________________________ Address: ____________________________________________
____________________________________________
Step 2: PAYMENT METHOD - SELECT ONE:
CREDIT or DEBIT CARD
VISA
Master Card
American Express
Discover
Card No.
Exp. Date ___ ___ / ___ ___ CVV (3 digits on back . AMEX 4 digits on front) ________
OR CHECK
Make checks payable to: Phoenix Children's Hospital Foundation
(Please attach check to Donation Form)
Notes (Do not write on back): ________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________
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